Frequently Asked Questions
Rheumatoid Arthritis
| Q. I have had some intermittent joint pain and swelling in my hands. How do I know if it might be rheumatoid arthritis? |
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A. You need to have a complete history and physical examination with a rheumatologist who can specifically tell you what type of arthritic problem you have. Rheumatoid arthritis is generally characterized by symmetrical joint swelling (in similar joints) like a mirror image on each side of the body. It particularly likes to attack the second and third knuckles (second and third MCPs) as well as the second and third middle joints of the fingers (second and third PIPs), but can involve other joints of the hands and wrists as well. Usually there is significant stiffness on awakening in the morning that may last longer than one hour. Rheumatoid arthritis also tends to attack the balls of the toes under the feet, which makes it painful to bear pressure on these areas with walking. The disease causes swelling and thickening of the lining of the joints, which is readily palpable by a trained physician like a rheumatologist. Laboratory studies may reveal elevations of markers for inflammation such as the erythrocyte sedimentation rate or the C-reactive protein. You may be positive for rheumatoid factor in your blood, which is present in 75% of patients with rheumatoid arthritis. X-rays may show evidence of joint space narrowing and erosions, which are typical of rheumatoid arthritis. |
| Q. I have rheumatoid arthritis and am a smoker and my doctor has been getting after me to stop smoking. Is it really necessary that I quit? |
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A. Patients who have rheumatoid arthritis and smoke are actually at more risk for lung disease than smokers who do not have rheumatoid arthritis. Thus this is a worse combination and you definitely should try to give up the cigarettes in order to live a longer and healthier life. |
| Q. I have read somewhere that rheumatoid arthritis doesn't just attack the joints, but also may involve internal organs. Is this true? |
| A. Yes. Rheumatoid arthritis may involve a number of organ systems in the body in addition to the synovial lining of your joints. There may be changes in the lungs themselves, or inflammation of the lining of the lungs (called the pleura), with even production of fluid in the chest cavity. Rheumatoid arthritis may involve the peripheral nerves leading to numbness and tingling from a neuropathy. The eyes may become inflamed particularly over the white part of the eye with what is called scleritis or episcleritis. In very rare and advanced cases of involvement of the eye, the cornea may thin allowing the contents of the eye to actually perforate, but fortunately this is an extraordinarily rare situation. Rheumatoid arthritis may affect the bone marrow so that the individual becomes more anemic in spite of taking iron therapy. Some patients may develop severe inflammation of the blood vessels leading to a loss of blood flow to the digits. This may cause serious problems including ulceration of the digits or even in rare and advanced cases gangrene. Sometimes the sac around the heart may get inflamed (this is called pericarditis). If fluid is produced within the pericardial sac, then this needs to be recognized as it might produce some compression of the heart and interfere with circulation. Even though I have mentioned these various other manifestations of rheumatoid arthritis aside from the joint involvement, it is important to note that these occur only in the most aggressive forms of this disease. Many of these problems are often associated with high titers of rheumatoid factor, but it is important to appreciate the fact that rheumatoid arthritis is a systemic disease and not just a joint problem. Therefore, you need to be under the care of someone who is familiar with all of these different ways rheumatoid arthritis may be expressed. |
| Q. I have been taking Motrin and Tylenol to get by and it takes away much of my pain, but I still have a great deal of swelling. Should I be doing something different? |
| A. Non-steroidal anti-inflammatory medications and aspirin do help alleviate some of the pain and swelling from arthritis, but it is critically important to control the inflammation in the lining of the joints with disease modifying medication. This may serve to prevent erosions and deformities. Once erosions occur in the first one to two years of your illness, your function is likely to deteriorate over time. Studies have shown that you are unlikely to regain your former functional status. Thus in patients with active rheumatoid arthritis, it is essential that they get started on specialized medication as soon as possible, particularly since so many new advances have occurred in the last few years that enable rheumatologists to better control your disease. |
| Q. One of my friends with rheumatoid arthritis is taking prednisone, but I thought that this was bad for you. Should I consider taking this medication if my doctor thinks I should be on it? |
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A. Prednisone at high doses is complicated by many side effects including osteoporosis, cataract formation, weight gain, facial swelling, hypertension, diabetes, and aseptic necrosis of bones. It is, however, an extremely potent medicine for reducing inflammation on an acute basis. It may be used in low dosages to help control some of the inflammation of the synovium that is present in the joints. If you are able to achieve a remission with highly specialized medications, your doctor may then be able to gradually taper you off of the prednisone. While you are on prednisone it is helpful to take adequate calcium and vitamin D supplements to try to combat the osteoporosis that may occur secondary to corticosteroids. |
| Q. My rheumatoid arthritis is taking a turn for the worse and my doctor is pushing for me to start on methotrexate, but I am afraid of this medication. Isn't it used to treat cancer? |
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A. Yes. You are correct that methotrexate has been used as a cancer medication in high dosages. In rheumatoid arthritis, however, methotrexate can be used in lower dosages on a once a week basis to control the underlying rheumatoid arthritis. It has been the most successful and popular disease modifying anti-rheumatic drug. Patients are able to stay on methotrexate for a longer period of time than popular previously used medications such as gold therapy. If your doctor is familiar with methotrexate and all its potential side effects and monitors you closely, then the risk of problems is diminished. Taking folic acid daily may cut down on some of the potential side effects of methotrexate. It is important that you do not drink alcohol while you are taking methotrexate and that your liver function tests are monitored on a regular basis along with your kidney function and your complete blood count. Rheumatologists use a great deal of methotrexate and would be quite familiar with how to prescribe this and how to monitor your laboratory studies. |
| Q. When should I consider joint replacement? |
| A. Generally joint replacement is performed when there is "end-stage" disease of the involved joint i.e. when there is no more cartilage with bone on bone. Function is generally greatly impaired with the pain becoming more and more unbearable. Joint replacements of the knee, hip and shoulder are done more commonly with those of the elbow and ankle still being developed. Each circumstance differs and informative discussions with your rheumatologist and orthopedic surgeon should take place. All three of you should be in agreement that a joint replacement is necessary and would be beneficial before you set out on this course of treatment with all of its associated risks. |
| Q. What about diet? Are there foods I can eat or should stay away from in rheumatoid arthritis? |
| A. Diets are much more complex. Recently a Norwegian study showed that a vegetarian diet was helpful in the treatment of rheumatoid arthritis. It is probably not going to be true for everyone. Certain foods have been shown to be helpful in reducing inflammatory proteins, most notably the fish oils or Omega-3 fatty acids. Omega-3 interferes with prostaglandin synthesis. Prostaglandins are proteins some of which can cause inflammation. The use of Omega 3 has been shown to reduce inflammation in rheumatoid arthritis. Unfortunately, the high dose required to reduce these inflammatory proteins is often complicated by loose stools/diarrhea. Overall a healthy diet is always recommended as well as maintaining an ideal body weight. This helps avoid putting more weight and pressure on the knees and hips with standing or walking. |
| Q. What are the dangers of joint replacement? |
| A. By far and away, infection is the most feared complication of a joint replacement. The possibility of blood clots forming after surgery exists and preventative measures need to be instituted. Otherwise there is a risk of one of the clots breaking off and lodging in the circulation of the lungs (pulmonary embolus). Discretionary use of antibiotic therapy intraoperatively and postoperatively are often employed by orthopedic surgeons. Careful wound management afterward is mandatory. Following a joint replacement if a patient sees a dentist for dental cleaning or a dental procedure, prophylactic antibiotics are generally recommended to prevent bacterial infection of the bloodstream that could then involve the joint replacement itself. |
| Q. Will I become disabled from rheumatoid arthritis? |
| A. Everyone is of course different. It depends on your clinical course and whether you have a more aggressive form of the disease. There are some patients who are treated with strong medications and yet still go on to develop disability. It now is clear from new data that the earlier your disease is treated and controlled, that the less likely you are to develop long term functional impairment. Newer treatments with Arava, Enbrel, and Remicade along with proper treatment with methotrexate offer hope of decreasing the rate of disability secondary to rheumatoid arthritis. |
| Q. What is seronegative rheumatoid arthritis? |
| A. Some patients have been diagnosed as having rheumatoid arthritis yet remain rheumatoid factor negative on their blood test. These patients are referred to as seronegative rheumatoid arthritis patients. Overall these patients have a better prognosis and a better survival rate. Fewer extraarticular manifestations are seen, but erosive disease may still be present nevertheless. One should always look out for other possible diagnoses such as systemic lupus erythematosus, psoriatic arthritis, and for the presence of microcrystalline deposits such as those seen in gout or pseudogout. |
| Q. Why do I need blood tests so often? |
| A. This is a commonly asked question by patients when they are first started on medications. Many of these medicines, such as methotrexate, can decrease the total white blood cell count or cause liver damage. A patient cannot ordinarily tell whether their white count is low or their liver has been affected by the medicine since these changes occur at first without any symptoms. Therefore blood tests are mandatory to rule out these side-effects. |
| Q. What is the best way to know that I am getting better with the treatment? |
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A. There are several ways that help both the patient and the physician to determine if the treatment has been successful. One, is the overall sense by the patient on how well he or she is doing. Generally, if a patient feels well over the course of several months while under therapy, that is the best sign that the therapy has been successful. With adequate treatment there may be a decrease in the duration of the morning stiffness which occurs with this disease. Also the number of joints that are tender to touch or are swollen will decrease significantly. The patient also may find that they can perform more of their daily activities without as much difficulty. Blood tests such as the sedimentation rate, C-reactive protein and rheumatoid factor level are helpful if they are abnormal before therapy but then normalize with treatment. |